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Employer Information

Employer and Division, Agency, or Department providing EAP benefit

Your Primary Information

First Name

Last Name

Relationship to employee

Date of Birth

Gender

Marital Status

Address

Apartment #

City

State

Zip

Personal email address

Name of health care insurance provider

Minor Dependent Information (Please complete the following information for the minor dependent)

Dependent's First Name

Dependent's Last Name

Dependent's Date of Birth

Dependent's Gender

Contact Information

Primary telephone

P - May we leave a confidential voicemail message?

Secondary Phone Type

Secondary telephone

Invalid value

S - May we leave a confidential voicemail message?

Best time/day for you to receive a call?

Time zone

Do we have your permission to send you an email link to our satisfaction survey?

Reason for your request

Request type

How would you best describe your request for assistance?

Please describe your current situation. What difficulties are you experiencing and are your main concerns?

Please rate the severity of your problem

How did you hear of the EAP Service?

Have you been told you are required to contact the EAP as a job performance referral?

Employment Information of the benefit holder

How many years employed at the company?

Is the employee full-time or part-time?

Is the employee currently working?

Is the employee a manager or supervisor?

Is the job in a safety sensitive position or regulated? (DOT, FAA, or Law enforcement)

If yes, name of regulatory agency

Additional Comments/Questions: Please include Cultural, Race, Ethnic, and LGBTQ identifiers that will help us process your request

Submit

FEI Behavioral Health, Inc.*

Employee Assistance Program (EAP)

On-line Service Request

All completed responses will be held by FEI Behavioral Health (FEI) as confidential. FEI does not share personal information with your employer.